Provider Demographics
NPI:1790178820
Name:KHOSHROU, BITA (DMD)
Entity Type:Individual
Prefix:DR
First Name:BITA
Middle Name:
Last Name:KHOSHROU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 COMMERCE DRIVE, SUITE 108
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:604 S WASHINGTON SQUARE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106
Practice Address - Country:US
Practice Address - Phone:855-342-5336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040269122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist